ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Use of health services by adult Latin American immigrants residing in Seville

Utilización de servicios sanitarios de los inmigrantes latinoamericanos adultos residentes en Sevilla

Utilização de serviços sanitários dos imigrantes latino-americanos adultos residentes em Sevilla

José Rafael González-López¹; María de los Ángeles Rodríguez-Gázquez²; María de las Mercedes Lomas-Campos³

¹RN, Ph.D. Professor Universidad de Sevilla, España. email: joserafael@us.es.

²RN, PhD. Professor Universidad de Antioquia UdeA, Calle 70 No. 52-21,Medellín, Colombia. email: maria.rodriguezg@udea.edu.co.

³MD, Ph.D. Professor Universidad de Sevilla, España. email: mlomas@us.es.

Receipt date: Mar 3, 2014 Approval date: Jun 3, 2014.

Article linked to research: Análisis de las conductas de salud y prevalencia de enfermedades de la población inmigrante y autóctona de la ciudad de Sevilla (PI-0138).

Subventions: Consejería de Salud de la Junta de Andalucía (Gobierno de España), en la convocatoria del año 2009 e implementado por la Facultad de Enfermería, Fisioterapia y Podología de la Universidad de Sevilla, España.

Conflicts of interest: none.

ABSTRACT

Objective.This work sought to describe the use of health services by adult Latin American immigrants from Seville. Methodology.This was a descriptive cohort study with the participation of 190 adult Latin American immigrants from 25 to 44 years of age, residing in the city of Seville (Spain) in 2011. A self-report survey was applied. Results. Within the past year, 67% of the individuals have visited a physician and 23% have attended nursing consultation. A total of 14% of the immigrants who called on a healthcare center reported that their experience was worse than that of others. La annual prevalence by accidents was: 10% domestic, 4% traffic-related and 9% occupational; nearly half these accidents justified emergency care or hospitalization due to their severity. The logistic regression model revealed that health services were used mostly by: women, those in poor self-perceived health status, those with secondary level of education, the elderly, and those who were single. Conclusion.The population studied presents adequate use of health services, although it would be recommendable to implement prevention activities by nurses in the immigrant's work and family environment to reduce the accident incidence described by this group.

Key words:emigration and immigration; Hispanic Americans; Spain; /utilization.

RESUMEN

Objetivo.Describir la utilización de los servicios sanitarios de los inmigrantes latinoamericanos adultos de Sevilla. Metodología.Estudio descriptivo de corte transversal en el que participaron 190 inmigrantes latinoamericanos adultos de 25 a 44 años residentes en la ciudad de Sevilla (España) en 2011. Se aplicó una encuesta que fue respondida por autorreporte. Resultados.En el último año, el 67% de las personas ha visitado al médico y un 23% ha acudido a la consulta de enfermería. El 14% de los inmigrantes que acudió a un centro sanitario reportó que su experiencia fue peor que la de otros. La prevalencia anual por accidentes fue: 10% doméstico, 4% de tránsito y 9% ocupacional; cerca de la mitad de estos accidentes justificaron la atención de urgencias o la hospitalización por su severidad. El modelo de regresión logística mostró que utilizaron más los servicios de salud las mujeres, quienes tenían mal estado de salud autopercibida, los que tenían estudios secundários y universitarios y los solteros. Conclusión.La población estudiada presenta una adecuada utilización de los servicios sanitarios, aunque sería recomendable implementar actividades preventivas por parte de la enfermera en el ámbito laboral y familiar del inmigrante para reducir la accidentabilidad descrita por este colectivo.

Palabras claves:migración internacional; Hispanoamericanos; España; /utilización.

RESUMO

Objetivo.Descrever a utilização dos serviços sanitários dos imigrantes latino-americanos adultos de Sevilla. Metodologia.Estudo descritivo de corte no que participaram 190 imigrantes latino-americanos adultos de 25 a 44 anos residentes na cidade de Sevilla (Espanha) em 2011. Aplicou-se uma enquete que foi respondida por auto-relatório. Resultados.No último ano 67% das pessoas visitaram ao médico e um 23% foi &agrave consulta de enfermagem. 14% dos imigrantes que foram a um centro sanitário reportaram que sua experiência foi pior do que a de outros. A prevalência anual por acidentes foi: 10% doméstico, 4% de trânsito e 9% ocupacional; cerca da metade destes acidentes, justificaram o atendimento de urgências ou a hospitalização por sua severidade. O modelo de regressão logística mostrou que utilizaram mais os serviços de saúde: as mulheres, os que tinham mau estado de saúde auto-percebida, os que tinham estudos secundários e maiores e os solteiros. Conclusão.A população estudada apresenta uma adequada utilização dos serviços sanitários, ainda que seria recomendável implementar atividades preventivas por parte da enfermeira no âmbito trabalhista e familiar do imigrante para reduzir a acidentalidade descrita por este coletivo.

Palavras chave:migração internacional; Hispano-Americanos; Espanha; /utilização.

INTRODUCTION

Although for centuries Spain had been a country of emigrants, during the last 20 years it has become one of the main receptor countries:² along the first decade of the 21^st century, immigrants went on to represent from 1.8% to 11.4% of the total population residing in Spain; in 2008, by region of origin 40% of the foreigners came from Europe, followed by 31% from South America.²

This migratory increase generated in Spain, similar to what has occurred in other counties around us, sparking great interest for knowing the implications of this phenomenon from different settings, among others that of healthcare. Research on the health of immigrants in Spain has identified that it is a young and healthy population with similar pathology to that of local populations.³ Another situation we must consider when studying this group's health is that the immigrant condition leads to increased social and health vulnerability.⁴ The study in our country on the access and use of health services by the immigrant group, as in countries with important tradition on said migrant phenomenon, has concentrated much of the scientific production.^5,6

Assuming the presence of the effect of healthy immigrants, there will be increased demand for health services as time of residency of the immigrants increases in the country of destination.⁷ In this sense, the time of residency again becomes a critical factor that will affect the level of use of healthcare resources of the receptor country, facilitating immigrant access to said resources or, on the contrary, creating barriers to their access and use.⁸ This new sociodemographic situation motivates growing interest on the study of the health situation of immigrants, aimed at accomplishing their equity and access to the healthcare system ensemble,⁹ therein, our healthcare legislation contemplates immigrants especially. The aim of this article has been to describe the use of health services by adult Latin Americans from Seville.

METHODOLOGY

This was a cross-sectional study, using stratified sampling with proportional allocation for the variables of sex, age, and administrative district, with the participation of 190 adult Latin American immigrants from 25 to 44 years of age.

This article presents the results of: a) sociodemographic data of those surveyed (sex, age, marital status, level of education, place of birth, time of stay in Spain, and occupation), b) access to health services, c) accidents, and d) informal care.

This research denominated immigrant as "that person who, having a country of origin different from Spain, at the moment of taking the survey has established regular residency within the national territory", which corresponds to the definition used by the National Statistics Institute in its National Survey on Immigrants for 2007.¹⁰ The data was collected in 2011. The selection criteria were: men or women residing in any of the Official Neighborhoods or Census Sections of the 11 administrative districts of the city of Seville; being between 25 and 44 years of age; having been born in any of the countries considered by the United Nations Organization in its classification of nationalities, territories, and regions as countries of Latin America or South America;¹¹ and having emigrated to Spain; being able to communicate and understand the study's requirements, and having signed the informed consent. The information was gathered by a single pollster.

To train the participants, diverse associations and groups of Latin American immigrants were contacted from the district to facilitate gathering the data. The procedures used to carry out this study followed the ethical principles stated in the Helsinki Declaration by the World Medical Association in 1964 (updated 2008); written informed signed consent was obtained, and, regarding sociodemographic data, to protect the honor, anonymity and personal intimacy the questionnaires were numbered, according to Legislation 15/1999 on Protection to Data of Personal Nature.

The data were analyzed with the SPSS statistical package version 22.0 for Windows. Descriptive analyses were performed, using measures of central tendency for the quantitative variables and dispersion and proportions measures for the qualitative variables. Relationships of some variables of interest were explored, using the statistics indicated for independent samples, thus: a) difference of proportions: Pearson's χ² test was applied if the percentage of the values expected from the boxes of contingency tables ≤5 were over 20%, on the contrary, Yates' continuity correction was used for χ²; and b) logistic regression: a step-by-step model was used, which introduced the dependent variable: use of health services, assigning the value of 1 for those who used them within the last 12 months and 0 for the opposite situation, and variables: age, sex, being married or partnered, level of studies, health status, months of residency in Spain and the age*sex interaction. The probability of entering the model was between 0.05 and 0.09 and the cutoff point of the classification table was 0.5; the statistical significance of each variable was examined through the individual β parameter. All estimated parameters were adjusted by the effect of the rest of the variables included in the block. Only the variables presenting statistical significance (p<0.05) were included in the subsequent models.

RESULTS

Sociodemographic characterization

The profile of the group of 190 individuals studied was the following: mean age was 33.8±6.3 years; 60% women; 45.3% were married, 36.8% were single, and 8.9% were living with a partner without being married; regarding level of studies, 3.7% had no studies, 15.3% had completed primary school, 40.0% secondary, 16.8% higher education, and the remaining 24.2% had university degrees. By country of origin, from the highest to the lowest contribution to the sample are: Bolivia (32.6%), Peru (18.9%), Colombia (16.8%) Ecuador (11.1%), Paraguay (5.2%), Chile (4.2%), Brazil (1.6%), Nicaragua (1.1%), and Argentina and Cuba (0.5% each). Analyzing the time of residency in Spain, it was found that the sample had a mean of 5.4±3.6 years. Regarding the current occupation, the highest proportions were found in employed by another (59.3%), followed by self-employed (18.4%), unemployed (10.5%), student (6.8%), and housewife (4.7%).

Table 1 shows that 87.9% of the participants scored their health status within the last month as good. Within the last 12 months 66.8% of the individuals had visited a physician for diverse reasons; the most frequent were acute pathologies (85.2%) like colds, stomach aches, backaches, spinal cord, and infections; 14.8% had visited due to chronic problems, like diabetes, hypertension and vision problems. It was found that for every three women consulting a physician, two men consulted, with this being a statistically significant difference. Almost one in every 10 individuals manifested not knowing their healthcare center, with women being half the proportion observed in men, a difference that remained on the border of statistic significance.

Only 23.2% of those surveyed had gone to nursing consultation. Of those, the most frequent motive was due to acute pathologies (71.7%) like headaches, gastritis, colic, as well as to have blood drawn and for health education; 16.7% attended because of colds and 11.7% for some cure procedure.

A total of 76.3% of the immigrants who visited a healthcare center within the last year were attended as were the rest of the people, but it is of concern that 13.7% reported that their experience was worse than that of others. Within the last year, 10.0% of the participants had suffered a household accident, another 3.7% had had a traffic accident and 9.0% had a work-related accident. A significant difference was found by sex in the household type in which women had a higher proportion than men. Regarding the severity of the accident, 71.4% (5/7) of those caused by transportation justified emergency care or hospitalization, with this proportion at 47.1% for occupational accidents and 47.3% (10/19) for household accidents. One in every four surveyed has been a caregiver within the last month, with the woman: man ratio being 3 to 1. Of the individuals who care for others, 66% (33/50) received some type of remuneration and 6% (3/50) reported deterioration of their health status because of the care they had to provide.

Table 1.Characterization of the variables related to health status and use of health services according to sex and total

Table 1.

*: χ² with Yates' correction, †: χ² (Pearson)

The logistic regression model for use of health services showed good general agreement (72.0%). The χ² probability value of the Hosmer-Lemeshow test accepts the null hypothesis that states that the model's theoretical distribution does not differ from that observed (χ²=4.54, p=0.715). Within the logistic regression model use of health services is a function of the variables of sex, self-perceived health status, level of studies, and being married or partnered. In general, it may be stated that health services were used more by: women, those with poor self-perceived health status, by those with secondary education and higher, and those who were single (Table 2).

Table 2.Results of the logistic regression for use of health services and some variables of interest

Table 2.

DISCUSSION

In this study of 190 adult resident immigrants, 87.9% perceived their health status as "good" within the last month; this is a robust health perception indicator in terms of lack of disease, functional limitations, and subjective health experiences.¹² Positive self- perception of their health status is a protection factor for the immigrant's mental health that can be affected by the loss of status, marginality, perceived discrimination, and fragility of the cultural identity experienced as residents in another country.¹³

It was noteworthy that 8% of the immigrants did not know their healthcare center, which coincided with López and Ramos¹⁴ who stated that the Latin American group is the one that knows best of said resources. A total of 66.8% of the sample had gone to see a physician at any given moment, similar data to the study on use of health services conducted by Rodríguez et al.¹⁵ In our study, the health problems for which the participants consulted are similar to those of other immigrant populations, and in turn are similar to those of the autochthonous population.¹⁶ Regarding attendance to nursing consultation, 23% of the sample sought for some type of care and health improvement. In this line of thought, research exists that conclude that the immigrant population consults less than the autochthonous population;¹⁷ data from the 2003 Spanish National Health Survey reiterates not having evidence that immigrants use health services excessively or inappropriately.⁵

Three of every four immigrants who attended a healthcare center perceived that they were treated equal to other groups; this may be due to, as stated by Bathum et al.,¹⁸ the fact that most Latin immigrants carry out an assimilation process; they start losing their own sense of identity to adopt that of the host society, favorably perceiving their new social environment. Regarding this point, a study was conducted on the acceptance of Latin American immigrants by the autochthonous population that states that this is the best valued migrant group.¹⁹ In spite of being among the groups least discriminated due to their origin, according to the study by Abizanda and Pinos,²⁰ 25% of Latin Americans feel discriminated or poorly valued; data above the 14% perceived in healthcare shown in our work. Latin Americans, according to Gómez Quintero,²¹ are seen by some Spaniards as the "younger siblings" or "poor relatives" and this perception, although not outright rejection, does hinder establishing relationships of social and legal equality, that is, of being seen - and seeing themselves - as citizens with full rights.

The issue of accidents in the immigrant population is a necessary element to be aware of to have a more realistic vision of the immigration situation in Spain, given the existence of obsolete and not very reliable data. Our study contributes that, within the last year, on average 9% of those surveyed have had some type of accident (10% at home, 4% traffic related, and 9% work related), with it being significant that said data is above the 7% of general accidents in the Spanish population during the same period.²² It should be highlighted that three of every four individuals who had an accident required attention from a health professional in a hospital or healthcare center, a figure above the 23% reported by Peiró-Pérez et al.,²³ in autochthonous population.

Regarding the 9% prevalence of work-related accidents in the participating immigrants, this figure is below the 15% described by Parra et al.,²⁴ in foreigners from Pamplona. According to Cachón,²⁵ said accident incidence can be in progression if several factors are combined like temporary employment rates (long and broken up work shifts), work stoppages (low wages) and level of work training. Questions on prevention of workplace risks and work health occupy a vastly secondary place, for immigrants and for most of the host and aid associations, given that the need for work, under any conditions, predominates initially over any other consideration.²⁶

It should be discussed that, in spite of the low prevalence of traffic accidents described in our work in the last 12 months (3.7%), this data tends to be higher in zones where immigrants have to travel many kilometers to go to their place of temporary work - given that, according Gómez Espín,²⁷ the acquisition of used vehicles by these foreign immigrants considerably increases the number of traffic accidents or accident rates, as also described by Koziol-McLain et al.²⁸ In terms of care giving, it is important that one of every four participants states doing so, mostly women. It is noteworthy that only 6% of the simple states that providing care has caused them some health problem, against 31% described by Valles Fernández et al.²⁹ It also seems notable that, of the total number of individuals who said they were caregivers, two thirds report having received some economic retribution. These data are similar to those reported by Neufeld et al.,³⁰ (236) who state that women immigrants were habitually caregivers, especially to their relatives. Said data are attractive, given that the high prevalence of Latin American women in household tasks and in agencies dedicated to their employment in households, as well as in caring for the sick in hospitals and/or homes. It is what is known as the incorporation of female migration onto "personal services" that according to migrant feminization is assumed mostly by women, according to Martínez Buján.³¹

In the logistic regression model, several sociodemographic factors were related to the use of health services: female sex, associated to a poorer perception of health status, with greater restriction of their activities,³² in individuals with secondary education and above, which agrees with that reported by Rodríguez and Stoyanova,³³ which states that an inverse relationship exists between the level of studies, as indicator of social class, and the use of health services; and in those who are single, considering marital status as a protective factor.³⁴ Our results permit supporting to a greater extent the theory of the "healthy immigrant", which, according to the bibliography worsens after 10 years of stay.³⁵ A good part of the studies dedicated to the health of immigrants has considered in their analysis of the "healthy immigrant effect",³⁶ which means that people recently established in the host country have better health indicators than the autochthonous individuals. One of the explanations for this phenomenon is given by the selective migration of people with better health status and higher economic capacity to face a migratory process, although differences can exist that can be attributed to the country of origin.

The population studied presents an adequate use of health services, although it is recommended to start visibility strategies of the healthcare centers and of nursing professionals to better assign health resources for this group. Additionally, it is fitting to implement prevention activities by nurses in the immigrants' work and family environment to reduce the incidence of accidents described. This study revealed some limitations that should be shared: participant responses to questions in the questionnaire were through self-report and were not verified, which can represent an error that involves every subjective response, which can be conditioned by factors beyond the reach of the researchers. Nevertheless, the anonymity of the questionnaires favored greater sincerity when answering questions. Another limitation is that the cross-sectional nature of the study did not permit establishing a causal relationship between the use of health services and the independent variables studied. However, it was possible to explore some associations, which would permit designing future analytic studies that will more accurately indicate the relationships of these variables.

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